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A UK Expert Consensus Approach for Managing Symptomatic Arteriovenous Fistula (AVF) Stenosis in Haemodialysis Patients

Abstract

Purpose

Stenoses in mature arteriovenous fistulas (AVFs) are common and can negatively impact on the quality of haemodialysis, the longevity of the AVF and lead to debilitating symptoms. Multiple treatment options exist; however, management can vary between different centres. We aimed to establish multidisciplinary consensus on the optimal stepwise application of interventions based on evidence and consensus.

Methods

A modified Delphi process was conducted with 13 participants from hospitals across the UK, all of whom have high-volume dialysis access practice.

Results

The usual intervention to rectify de novo stenoses of mature AVFs is fistuloplasty, although surgery for inflow segment stenoses is also clinically acceptable. Appropriate first-line interventions include plain old balloon angioplasty or high-pressure balloon angioplasty; if these fail during the fistuloplasty, consider upsizing the balloon, prolonged balloon inflation or using alternative interventions, such as cutting or scoring balloons and ultra-high-pressure balloons. Alternative or subsequent interventions vary by anatomical site and may require additional multidisciplinary team input. For a stenoses recurring between 3 and 12 months, it is appropriate to consider interventions used de novo, but with a lower threshold for using drug-coated balloons (DCBs) in all regions and for using stent grafts in all regions but inflow segment. Recurrence after 12 months should be treated as a de novo lesion, with DCBs considered if they have been used successfully during previous interventions.

Conclusions

These recommendations aim to provide a practical guide to multidisciplinary teams in order to optimise the use of multiple interventions for rectifying AVF stenoses and provide unified evidence-based practice guidelines.

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Acknowledgements

The authors would like to acknowledge the support of K McKillen in facilitating the Delphi meeting and K McKillen and Prescript Communications in preparing the manuscript.

Funding

This study was funded by Bard Limited. All authors received participant’s honoraria from Bard Limited to attend the meeting; however, the views and opinions reported are those of the authors only and were not influenced by Bard Limited. Bard Limited is now a wholly owned subsidiary of BD (Becton Dickinson & Company).

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Correspondence to Ounali Jaffer.

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Jaffer, O., Gibbs, P., Gibson, M. et al. A UK Expert Consensus Approach for Managing Symptomatic Arteriovenous Fistula (AVF) Stenosis in Haemodialysis Patients. Cardiovasc Intervent Radiol 44, 1736–1746 (2021). https://doi.org/10.1007/s00270-021-02875-5

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Keywords

  • Stenoses
  • Arteriovenous fistula
  • Fistuloplasty angiography
  • Dialysis access intervention
  • Haemodialysis